Health Care, Solved

I tried this on Facebook and nobody bit but I like it and so I'll try again.  That is: couldn't we just give health care to the NSA?  That way we could do away with all those silly applications--they already have all they need on file.  And while we are at it, we could turn over spying to the folks at HHS.

What Can Happen When You Extend Health Care

The Economist tells us what can happen when you extend health care to "the overwhelming majority" of your people:

Mexicans’ health has perked up dramatically in some areas. Since 2008, when Seguro Popular began providing a vaccine against rotavirus, a common cause of diarrhoea, deaths from the illness have fallen by 60%. When the programme started to pay for treatment of acute leukaemia in children, the survival rate improved from three in ten to seven in ten. Nearly a third of women with breast cancer used to abandon treatment because they could not afford it. Since 2008, when treatment became free, the drop-out rate has come down almost to zero.

Insurance has saved many people from another affliction: poverty. When the poorer half of the population had to pay for medicines or procedures not covered by state hospitals, millions of families were bankrupted by illness. Julio Frenk, a former health secretary who oversaw the beginning of Seguro Popular and is now dean of Harvard’s School of Public Health, recalls meeting a family in which the mother had needed a Caesarean section and the baby had spent a couple of weeks in intensive care. The child survived, but the medical bill cost his father his animals and tools and meant that his brother had to be taken out of school. “People liquidated their productive assets and their poverty was transmitted to the next generation,” says Mr Frenk. Until the late 1990s nearly 7% of families were dragged below the poverty line each year by medical emergencies. By 2010 the figure had fallen to less than 3%.

 Link.

Great Idea, Great Concept

Here's a rhetorical problem: how to write this post without making it sound like I'm reporting on a topless mud wrestling cage match.  I.e., to make it important without making it just lurid.

The core point: Austin Frakt, health care economist and blogger, is setting up a "conversation"--I will not call it a debate--with health care economist and book-author John Goodman.   I should say this is a wonderful idea.  Love him or hate him,  you have to concede Goodman is a grownup on issues of health policy.   And if anybody can reeducate him while remaining temperate and respectful, it would have to be Frakt.  It may not work--Frakt has already reserved the right to video a public immolation (of the book, not Goodman) if it goes off the rails.  But these guys have at least half a chance.

And is it just remotely possible that this is an idea we could generalize?  The web has unambiguously proven its power to obliterate the landscape with shitstorms. But through it all there are still people who perversely insist on using it to generate useful content.

They'd have to find each other, of course.  I'm not suggesting an internet commissioner of rhetoric.  And I suppose you can say we already find pockets of this sort of thing in stuff like  blogginheads talks.  I'm just looking for a path to generalize.

A final note:  be it recorded that I'm not necessarily looking for a "path to a center," built on the hypothesis that "civilized people can come to agreement."  Properly done, I'd say the forecast is very likely not.  But even without syncretism, I'd like to believe that there is still some room for low-voltage disagreement, where people with heft can agree to disagree, perhaps even while clarifying each others' thinking.  So, go John and Austin. But I admit I probably will check in to watch the incineration, if and when. 

How We Live Now

By almost any measure, Palookaville and its surrounding county are pretty small potatoes.  We're only 220,000; about 15 percent Hispanic, with more Native Americans than African-Americans, more Asians than either.  There are some pockets of social stress: the relatively large Hmong cohort is about the same size as the minuscule African-American population.   If you count the non-profit hospital as "public," then this is a "public sector" town: the top six private employers in aggregate have fewer employees than the hospital, or the university, or the pubic school system.   So, a pretty stable, solvent, well-manicured environment.

All by way of background for this morning's sighting:  from a bin in a food store, something called the county "Medical Directory"--an advertising promo, that is: one-line listings plus a scattering of display ads for medical services.  Altogether, something like 50  pages.   This is not all MDs.  The alphabetic index includes, I don't know, maybe 30--maybe 50?--medical specialties, but also dentists and chiropractors, midwives, hearing aid dealers, nutritionists, opticians, optometrists, opthalmologists, all tucked in between oncologists and orthopedists.  You get the idea.

And I certainly do not mean to sneer; I am the happy consumer of a variety of these services.  And like (I suspect) many of the consumers, my capacity to consume is a function of Medicare in conjunction with a generous public employment package benefit.   And I'd turn that point around: suppose we abolished all Medicare and public employee benefit plans from this county: how many pages of this directory would just vanish like the leaves?   I expect quite a lot.  

I gave some numbers above on public versus private employment: actually the largest non-public employer in Palookaville is Walmart (number five on the top-ten-employer list).   The largest old fashioned "make-something" employer is the brewery. It weighs in at number six, with a work force about 14 percent the size of the workforce at the hospital.   I once heard the economist Lester Thurow, explaining the concept of a gross national product, remark that "I mean we can't get rich just by all taking out each other's appendix."  He hadn't seen Palookaville.

You Knew That, But...

...here it is again:

Much important work is done by people with sore backs and calloused hands who don’t get paid that much...

So this guy, whose car gave out on the Dan Ryan Expressway.

There Ain't No Free Health Care

Look, I'm all in for some sort of government-sponsored universal health care.  We may (and perhaps should) dicker over particulars,  but I think ObamaCare is a fine start and I'm glad the Supreme Court thought so too.

But I do so wish that people who should know better (I'm talking to you, little Kevin Drum) keep calling it free health care (KD: "free, universal healthcare funded through the tax system").

Once again from the top, kiddies: if it is tax supported, it is not free.   Somebody is paying for it,  Maybe even you.   I'm not entirely certain why we are so diffident about saying so; my best guess is that the crazies have so hijacked the debate that any embrace of the T-word in any context anywhere  is like endorsing one of those ick-factor examples Jonathan Haidt and his pals like to dream up for their (fiendish) morality experiments.

There are all kinds of reasons why we should talk about taxes.  "Fairness up" is one; it's important to know that a guy who wants to be president walks away with one of the lowest overall tax rates in captivity.  "Fairness down"  is another; it is equally important to know that a good bit of taxation takes money from the relatively less well off to make life easier for th cosseted and comforted.
But in this context, a more important reason is that to talk about "free" health care makes us looks like idiots.  It makes us sound like we don't know that stuff costs money.  "Hey, I never meant that!" says a hypothetical Kevin and of course he did not mean it.  But he doesn't want to have to waste time and money explaining an irrelevancy.   In brief, don't make life easier for the wingnuts.  They've got it easy enough already.

Afterthought: I think I have probably outed myself as a type-four conservative--on Vagabond Scholar's chart, the ones in the blue box in the southeast corner.  As VS says,  folks in this cohort  "make up the smallest portion by far" off his four-way analysis.

Health Care Explained

There, that about gets it:

Much of the white population remains convinced that what BHO and the Democrats did in the ACA was to; divest most whites of their existing health care and force them into insurance pools that they do not want, cut the Medicare Advantage programs that whites love, cut the growth of Medicare by at least $500 billion, establish "taxes" for those who do not choose to have health insurance but who could afford it, subsidize "pool" membership for people who can pay part of health insurance but not all (read mostly minorities in white minds) and then axpand Medicaid for those who can't pay at all (more of the same in white minds).  Most white people believe that they will end up paying for all this.   One must remember that most low income people in the US pay no income tax at all.   This attitude does not apply in the minds of the "Morning Joe" crowd in New York City, LA, etc.  They are filled with righteous satisfaction for the poor and righteous indignation against the white middle class in flownover America.

So Turcopiler. Follow the link to let him show you how the NAACP let itself get gamed.  Oh, and there's this.

A Meta Comment on Health Care

I've been traveling and so not in the thick of the health care aftershocks (though they certainly seem strong enough to register on the seismograph at Caltech), but I want to add a meta-comment or two, chiefly about pattern of the followup.  Specifically, I'm fascinated to see how quickly and completely the blogosphere back-engineered the Scalia "dissent" to show that he thought he was writing (perhaps better, "taking a victory lap") for the majority: for a good selection of evidentiary exhibits, search here.  I'm also intrigued by the suggestion that it was intentional--that Scalia dropped those Easter eggs precisely so the world would know utterly he had been betrayed.  Could be, but his seems a bit of a stretch to me, more than a little like suggesting you look for the acrostic to show that Bacon wrote Shakespeare. 

I'm more intrigued--but would still count it as speculation--that the victor/villain in the case is Justice Ginsberg, who seems to have trolled "tax" past Justice Robert's nose in a way that induced him to take the bait.  That is: could be, but we would need a bit more compelling evidence (which, God wot, we will never get, or perhaps not for another 50 years).

I confess I have spent a few minutes with the shrieking hyperbole of the right-wing noise machine and I have to ask--isn't there some point, somewhere, at which all this becomes self-defeating?    At the very least, you would think folks would catch on that what these guys are really fighting is each other as they scratch claw for dominance before the (admittedly very profitable) public megaphone.

I'd also give the last word to Orin Kerr,  pointing out that the case was decided on the barest of technicalities and that there are any number of other legislative routes under which health care (aka,  the end of western civilization as we know it) might have emerged without any doubts as to its constitutionality.

Is Health Care Iwo Jima?

Geopolitics boffins like to draw the distinction between strategy and tactics (maybe strategy, operations and tactics, but it's a detail).  They point out that tactical victories can lead to strategic defeats.  Exhibit A: Pearl Harbor, perhaps the greatest tactical victory of the 20th Century.  It brought America into the war and led to the destruction of the home islands.  Had Japan simply tended to its Pacific knitting and ignored the United States, it might (we can imagine) have built itself a secure Pacific Empire.   Indeed, Japan was still enjoying something close to tactical victory until almost the last days of the war (think Okinawa, Iwo Jima).  And without these tactical achievements, it might not have suffered the atomic attacks, maybe not even the firebombing of the great cities.

So, is the Romney Obamacare decision Iwo Jima? Will it so energize the insulted and injured that they will come roaring to victory in November, and repeal after that?

We Don't Need No Stinkin' [See infra, passim]

Ooh, heads will roll: WSJ op ed speaks well of health care and pensions.

The Courtwatchers: What are they Hearing?

My court-watching skills--Supreme, or otherwise--are just about zero.    This insight hasn't stopped me from assuming that Obamacare is toast, long before the route walkover oral argument yesterday morning.  I'm impressed that so many of my better informed colleagues thought--and from what I can tell, still think--that might have a chance,  In that context, David Frum weighs in with some fascinating comments from a guy who seems actually to know what he is talking about: go here.  Frum also offers a fascinating account of why a Republican "victory" may be a poisoned chalice; go here.

This is What it Comes To, Not So?

They want health care all right and they want the government to pay for it.  They just don't want to have to take it from a black guy. Cf. link.

Annals of Health Care: an Amsterdam GP

A couple of days ago here in Amsterdam, we came through one those medical Euromoments that American tourists love to tell about back  home. We have nothing to add to the conventional wisdom but I'll tell the story anyway. Plot spoiler, it ends well.

Anyway, Mrs. Buce came home from a day on the town experiencing those symptoms you know are probably nothing, but could be something awful. A brief Google inquiry proved equivocal, so we made a  phone call to the lady who had delivered our apartment keys.  Oh, she said, there is a doctor right next door. I mean  literally.  Next door.

We popped on over--this was about twenty to five in the afternoon and sure enough, there was a little doctor-symbol.  We opened the door into a long narrow hallway.  We could see a light behind an open door at the back. There were two empty chairs.  Almost out of sight in a recess at the top of a stairway was a woman seated behind a little tea-table with an Apple laptop.  After about three questions, she said--well, the doctor can see you in a few minutes but he has to make a couple of phone calls first.  Do you have insurance?  Tourists?  Well, you'll have to pay now but we'll give you a receipt to take home.

Sure enough, after about five minutes, a slender little man in levis and open shirt popped out from behind the lighted doorway.   Indian, I'd guess, though more from the name on his card than from appearance.  He took us back to a largeish, mostly empty, room, where he seated himself behind another Apple laptop.  I say "mostly empty:" actually, there were bits of apparatus in various corners that looked like they might be diagnostic equipment. There were some shelves with piles of papers that might have been document unfiled since the Great Tulip Mania.

Mrs. B gave her her account.  The doctor (he is a doctor, yes?) responded quickly that he didn't think it was anything to worry about.  He took one brief look at the trouble spot and said--no, probably nothing.  But if it gets worse, you can come back.  And let me give you the address of an all-night first-aid center.  Most of the conversation was reassurance; he did indulge himself with some not-so-sly digs at the excesses of  US medicine. And he fielded a couple of phone calls from (as he said) the hospital, reporting on patients he had seen earlier in the day.  His Iphone ringtone is the quacking duck.

And then he typed a bit on his laptop and printed us on a receipt and sent us off.  The girl at the desk took our money? Visa?  No, but there is an ATM in the street if you need it.  And we were on our way.

I know, I know. The point is the total non-eventness of this event.  And the low overhead: one front-desk person, but no nurse, no nurse practitioner, no physician's assistant--and most of all, no biller. Here, I suppose I echo Paul Krugman's point about as defining feature of American medicine, i.e., the amount of time and money we spend establishing liability for (i.e., "getting out of") paying claims.  Had we had a local card, I suppose the young woman would have slipped it into a card-reader and that would have been that.   There is also--I am more tentative here--the question of malpractice.  Is it so that the doctor can be casual because he doesn't have to worry about being sued?   Anyway, the story is that there isn't any story and that's the story.  And the ringtone duck.

Today's Number: Seven

Number of dialysis machines in Uganda (pop. 32.7 million) (link).

There Ain't No Free Market

Off to accompany the troops to Chartres this morning (perhaps in the rain), but in my absence, take a few minutes to absorb Austin Frakt on one of my favorite themes: there's no such thing as "the market;" there are markets and markets, and some while others work pretty well. Same goes for government, and recognizing this insight makes so much of current debate just noisome gas.

Travel afterthought:  as a geezer traveling with teenagers, I have many occasions to wonder--are they traveling with me, or am I traveling with them?  Or, as is beginning to seem more likely, are they traveling and I trotting along behind?

Romney and Freedom, with a Note on Health Care

Oh boy, if Mike Huckabee or Sarah Palin or Michelle Bachmann said it, you could write it off as just wilful ignorance or batshit looniness, but when Mitt Romney says that we are  "only inches away from ceasing to be a free market economy," you'd just have to write it up as an arrogant, insolent, baldfaced lie.  Which is pretty much what they are calling it  over at Politifact, the Poynter journalistic fact-checker (sourced, ironically, in large measure, to those bomb-throwing insurrectionists at the Heritage Foundation).

Poynter confers particular attention on the Heritage economic freedom index for 2011, on which the US ranks ninth from the top "freest") out of 179  (actually 183, adding four more "states" where government is so chaotic they cannot be ranked--a kind of freedom itself, of course). None of this is surprising to anyone of even mildly wonky sentiments, a group which clearly includes Romney himself.  But here's an extra irony I hadn't noticed before: health care.  Namely that every one of those top eight has some kind of universal public health care.  And they virtually all get better results than the US has, and at substantially less cost.

Local mileage may vary, of course, and each of the eight eight solves the problem in differnt ways. I suspect that Singapore (number two on the list) provides relatively the smallest amount of direct government cash.  But (as Bryan Caplan makes clear, in a generally approving review) there is nothing remotely "free" about the Singaporean health care system: shorthand, it's a mix of compulsory savings  and means-tested backup, plus a (dare one say it?) public option.

 I dunno, maybe Romney (who can clearly say anything with the same schoolboy grin) will soon be telling us that Singapore and Hong Kong (and Switzerland, and Denmark, and Canada, and Ireland, and New Zealand, and Australia) are just mired in post-Leninist purgatory.    Others might say otherwise: they might say it shows that freedom can be enhanced (even on a  Heritage definition) by the right kind of government intervention.  Like, say, in Massachusetts.  

Jost on ObamaRomneyRyanCare

Professor Timothy S. Jost from Washington and Lee Law School has put together a commendably boring comparison of ObamaCare, née RomneyCare and what is, on Jost's account, its new avatar as RyanCare.  As Jost offers, with wonkish restraint:

Exploring the shared elements of the two plans [allows one] to clarify the extent to which consensus has emerged in U.S. health policy may enable us to begin addressing the serious conflicts that remain.

Well it might.  As Jost makes clear, in terms of structure and strategy, the similarities vastly outweigh the differences (Kevin Outterson points out that Ryan even has an individual mandate--query, is the whole package unconstitutional coming out of the gate?).  But I wouldn't hold my breath about "addressing" here:  There are at least two good reasons why this will never happen.  One, the Republican's indisputable first principle that it is more important to destroy Obama than it is to pass any program, no matter how plausible and widely desired. And two, to distract attention away from the point that Ryan's plan is so much more chintzy less generous than Obama's.

I admit that I don't have a firm, unalterable position on the chintzy/generous scale. It still seems to me that we're having far too little discussion about the reasons for the high costs of health care. How would the world change if we could use our Medicare dollars in Bangkok or Bangalore, for example? Is the FDA really moving as fast as it should on the approval of economizing devices? Just in general, I wish I had a better informed view about how the competing plans deal with the matter of competition among health care providers. I'm inclined to suspecct that RyanCare does next to nothing, but it's not obvious to me that ObamaRomney does much better.  

Health Care as "Fixing Broken Windows"

 I'm reading with interest the reports on a new paper by David M. Cutler that repealing Obamacare would cost 250,000 to 400,000 jobs annually over the next ten years.  I'm not the one to evaluate the accuracy of the estimate although I accept the narrow premise that losing all those jobs would be a Bad Thing.  Still, shouldn't we feel a bit dicey about an economy that depends so much on our common infirmity and malaise?  Wasn't it Lester Thurow who said that we can't all get rich taking out each others' appendix?*

Don't misunderstand, I take second place to no one in my affection for my doctor: were it not for the great good fortune of reasonably good health, I'd want to have her on my speed dial.  And there are plenty of health misfortunes (like, I suppose appendicitis) that just happen.  But it's surely true that a lot of our health-care costs are the result of rotten lifestyle choices--obesity, smoking, whatever (well--obesity and smoking cover a lot).  Fixing the damage of obesity and smoking is a lot like fixing those broken windows that should never have broken in the first place, as in Bastiat's great fable.

[Aside from "unavoidable" costs, other reason's why I'm wrong: some portion of health care spending (and employment) is "prevention"--trying to keep those windows from being broken in the first place; and some is "research:--trying to make the health care pie higher, as they say.  Still...]
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*Thurow: I was going to ask--"whatever happened to that guy, anyway?  Turns out he is still going strong.   But in a winner-take-all society, if you're not Paul Krugman, I guess you're not much.

Wish I'd Thought of That

Daniel Gross has the best idea of the day.

Another Casualty of Massachusetts: Health Care Cost Control

Once again, James Kwak administers a reality slap in the health care debate. Forget about "health care" broadly defined: focus on trying to get something, anything that will put the reins on longterm health care costs.

Kwak (largely amplifying Jonathan Gruber) argues that the Senate bill is that rarest of all Congressional species: a genuine-honest-to-god, money-where-your-mouth-is attempt to get a saddle and bridle onto the ever burgeoning cost of health care.

Some one more casualty of the GOP victory in mass: spending sanity. Thanks, GOP.